Healthcare Provider Details

I. General information

NPI: 1083920607
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA MEDICAL DIAGNOSTICS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 S CENTRAL AVE
GLENDALE CA
91204-2212
US

IV. Provider business mailing address

PO BOX 10094
GLENDALE CA
91209-3094
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-0004
  • Fax: 213-484-0088
Mailing address:
  • Phone: 818-244-4646
  • Fax: 818-244-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License NumberG43636A
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberG43636A
License Number StateCA

VIII. Authorized Official

Name: SIM C HOFFMAN
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 714-995-5400